Viability and Outcomes With Revascularization or Medical Therapy in Ischemic Ventricular Dysfunction
Authors: Divaka Perera, Matthew Ryan, Holly P. Morgan, John P. Greenwood, Mark C. Petrie, Matthew Dodd, Roshan Weerackody, Peter D. O’Kane, Pier Giorgio Masci, Muhummad Sohaib Nazir, Alexandros Papachristidis, Navtej Chahal, Rajdeep Khattar, Saad M. Ezad, Stam Kapetanakis, Lana J. Dixon, Kalpa De Silva, Adam K. McDiarmid, Michael S. Marber, Theresa McDonagh, Gerry P. McCann, Tim C. Clayton, Roxy Senior, Amedeo Chiribiri, Gerry Carr-White, Antonis Pavlidis, Simon Redwood, Brian Clapp, Aldo Rinaldi, Haseeb Rahman, Natalia Briceno, Sophie Arnold, Amy Raynsford, Margaret McEntegart, Stuart Watkins, Aadil Shaukat, Paul Rocchiccioli, Louise Cowan, Ceri Davies, Elliott Smith, Bhavik Modi, Jehangir Din, Jonathon Hinton, Jonathan Blaxill, Abdul Mozid, Michelle Anderson, Simon Walsh, Mark Spence, Patricia Glover, Richard Edwards, Mohaned Egred, Hannah Stevenson, George Amin-Youssef, Ajay Shah, Jonathan Byrne, Nilesh Pareek, Jonathan Breeze, Anthony Gershlick, Andrew Ladwiniec, Iain Squire, Donna Alexander, Julian Strange, Tom Johnson, Angus Nightingale, Laura Gallego, James Spratt, Claudia Cosgrove, Rupert Williams, Sam Firoozi, Pitt Lim, Dwayne Conway, Peter Swoboda, Paul Brooksby, James Cotton, Richard Horton, Stella Metherell, Kai Hogrefe, Adrian Cheng, Sian Sidgwick, Tim Lockie, Niket Patel, Roby Rakhit, Fozia Ahmed, Cara Hendry, Farzin Fath-Ordoubadi, Douglas Frazer, Mamas Mamas, Miles Behan, Alan Japp, Nicholas Jenkins, Sam McClure, Karen Martin, Eltigani Abdelaal, Jaydeep Sarma, Sanjay Sastry, Jo Riley, Pradeep Magapu, Rod Stables, David Wright, Michael Mahmoudi, Andrew Flett, Nick Curzen, Sam Gough, Zoe Nicholas, Andrew Ludman, Hibba Kurdi, Sam Keenan, Kevin Thorpe, Prithwish Banerjee, Luke Tapp, Abeesh Panicker, Mark De Belder, Jeet Thambyrajah, Neil Swanson, Neville Kukreja, Mary Lynch, Girish Viswanathan, Elaine Jones, Sarah Norman, Helen Routledge, Jasper Trevelyan, Nick Pegge, Sukhbir Dhamrajit, Tim Wells, Manas Sinha, Gavin Galasko, Christopher Cassidy, Tim Edwards, Javed Iqbal, Fraser Witherow, Kaeng Lee, James Beattie, Mike Pitt, Julian Gunn, Abdallah Al-Mohammad, Helen Denney, Huw Griffiths, Paul Kalra, Tim Gray, Jolanta Sobolewska, Steve Ramcharitar, Laura McCafferty, Thomas Martin, John Irving, Zaid Iskandar, Jason Glover, James Beynon, Maurice Pye, Simon Megarry, Paul Das, Chris Bellamy
Journal: JAMA Cardiology (2023)

Importance In the Revascularization for Ischemic Ventricular Dysfunction (REVIVED-BCIS2) trial, percutaneous coronary intervention (PCI) did not improve outcomes for patients with ischemic left ventricular dysfunction. Whether myocardial viability testing had prognostic utility for these patients or identified a subpopulation who may benefit from PCI remained unclear. Objective To determine the effect of the extent of viable and nonviable myocardium on the effectiveness of PCI, prognosis, and improvement in left ventricular function. Design, Setting, and Participants Prospective open-label randomized clinical trial recruiting between August 28, 2013, and March 19, 2020, with a median follow-up of 3.4 years (IQR, 2.3-5.0 years). A total of 40 secondary and tertiary care centers in the United Kingdom were included. Of 700 randomly assigned patients, 610 with left ventricular ejection fraction less than or equal to 35%, extensive coronary artery disease, and evidence of viability in at least 4 myocardial segments that were dysfunctional at rest and who underwent blinded core laboratory viability characterization were included. Data analysis was conducted from March 31, 2022, to May 1, 2023. Intervention Percutaneous coronary intervention in addition to optimal medical therapy. Main Outcomes and Measures Blinded core laboratory analysis was performed of cardiac magnetic resonance imaging scans and dobutamine stress echocardiograms to quantify the extent of viable and nonviable myocardium, expressed as an absolute percentage of left ventricular mass. The primary outcome of this subgroup analysis was the composite of all-cause death or hospitalization for heart failure. Secondary outcomes were all-cause death, cardiovascular death, hospitalization for heart failure, and improved left ventricular function at 6 months. Results The mean (SD) age of the participants was 69.3 (9.0) years. In the PCI group, 258 (87%) were male, and in the optimal medical therapy group, 277 (88%) were male. The primary outcome occurred in 107 of 295 participants assigned to PCI and 114 of 315 participants assigned to optimal medical therapy alone. There was no interaction between the extent of viable or nonviable myocardium and the effect of PCI on the primary or any secondary outcome. Across the study population, the extent of viable myocardium was not associated with the primary outcome (hazard ratio per 10% increase, 0.98; 95% CI, 0.93-1.04) or any secondary outcome. The extent of nonviable myocardium was associated with the primary outcome (hazard ratio, 1.07; 95% CI, 1.00-1.15), all-cause death, cardiovascular death, and improvement in left ventricular function. Conclusions and Relevance This study found that viability testing does not identify patients with ischemic cardiomyopathy who benefit from PCI. The extent of nonviable myocardium, but not the extent of viable myocardium, is associated with event-free survival and likelihood of improvement of left ventricular function. Trial Registration ClinicalTrials.gov Identifier: NCT01920048